Psychotherapy. James Joseph Walsh
target="_blank" rel="nofollow" href="#n22" type="note">22 delivered at Edinburgh in 1896, Prof. T. S. Clouston, the distinguished English psychiatrist, has a passage on this subject that deserves to be recalled:
[Footnote 23: British Medical Journal, January 18, 1896.]
I would desire this evening to lay down and to enforce a principle that is, I think, not sufficiently, and often not at all, considered in practical medicine and surgery. It is founded on a physiological basis, and it is of the highest practical importance. The principle is that the brain cortex, and especially the mental cortex, has such a position in the economy that it has to be reckoned with more or less as a factor for good or evil in all diseases of every organ, in all operations and in all injuries. Physiologically, the cortex is the great regulator of all functions, the ever active controller of every organ and the ultimate court of appeal in every organic disturbance.
Psychotherapy in Its Relation to Patient and Physician .—In spite of the present-day fad for psychotherapy, I have no illusions with regard to its popularity among patients, unless practiced with due regard to individuals and with proper tact. Psychotherapy has been most effective in the past when it was cloaked beneath the personality of the physician; when it was felt that there was in him a power to do good that must help the patient. This personal influence has to be maintained if the patient's mind is to be influenced favorably. Very few people are willing to think, and still less to welcome the thought, that they themselves are either bringing about a continuance of their symptoms or are hindering their own recovery. They are quick to conclude that this would be a confession that their ills are imaginary. "Imaginary" has no place in medicine. There are physical ills and mental ills. Mental ills are just as real as physical ills. There are no fancied ills. A person may be ailing because he persuades himself that he is ailing, but in that case his mind is so affecting his body that he is actually ailing physically, though the etiology of the trouble is mental.
It is the duty of the physician to get at these mental causes of physical ills and remove them by persuasion, by reassurance, by changing the mental attitude, by making people understand just how mind influences body, but this must be done tactfully. From the beginning of time we have written our prescriptions in such a way that ninety-nine out of one hundred patients have not been able to understand them. It has often been said that we should change this method of prescription writing, and write directions for the compounding of our medicines in plain vernacular. Besides the many scientific reasons against this, it is better for patients not to know exactly the details of their treatment. Physicians, because of their real or supposed knowledge, are usually the worst patients. If, when a physician is ill, a drug is administered in which he has lost confidence, he will really oppose its action by contrary suggestion, and perhaps neutralize it. Confidence added to the action of the drug itself, makes it much more potent and much more direct. Hence the suggestive value of a prescription the ingredients of which are unknown. Every physician knows of patients who have declared that a drug has been tried on them without avail, when it has only been used in such small quantities as to be quite nugatory in its effect. Such use was enough to prejudice them against it so that when given in physiological doses it failed to work properly.
Opium given to a trusting patient, in gradually reduced doses until practically there is nothing but the flavor of the drug in the compound that he takes, will continue to have its effect. But to a patient prejudiced against the drug, even large doses of opium will prove unavailing, because the lack of confidence disturbs the mind, directs attention to whatever discomfort may be present, emphasizes the ill and prevents sleep by preoccupying the mind with the thought that neither the drug nor the dose can accomplish its purpose. In a word, medicine plus mental influence is extremely valuable. Medicine minus mental influence is valuable but sometimes ineffective. Medicine, with mental influence opposed to it, is often without effect because of the strong power the mind has over bodily functions.
Most people would rather be cured by some supposedly wonderful discovery, which presumedly made it clear that they had been suffering from a severe and quite unusual ailment, than by ordinary simple methods. The recent growth of interest in psychotherapy and psychology has, however, somewhat prepared people to accept mental influence as an important factor in therapeutics. The direct and frank use of psychotherapy will be of benefit to these people. But in most cases mental influence will have to be exerted in such a way as to conceal from patients that it is their own energy we want to tap to help them cure themselves. This would be for them quite an unsatisfactory method of being cured. In practically all cases such a combination of methods is needed that the place of mental influence is not over-emphasized. As a rule, mental influence must not be used alone. Its place is that of an adjunct, a precious auxiliary, to other methods of treatment.
Psychotherapy represents one of the important elements in therapeutics, and we must learn to use it in a way suitable to our patients. We have to learn to use our drugs in accordance with the nature and physical make-up of the patient. We have to find out by experience just how to use hydrotherapy for each individual. Varying currents of electricity and varying forms of electrical action are needed for different individuals. Just in the same way, our psychotherapy must be dosed out according to the special need of each individual, the form of the affection and the particular kind of mind that is to be dealt with. To learn the place of mental influence in healing, so that we shall not be attributing to other therapeutic factors what is really due to the mind, will be a great advance in therapeutics. This is the mistake that we have been making in the past.
In brief, the applications of the general principles of psychotherapy include all means, apart from the physical, of influencing patients. Drugs will always have a large place in rational therapy. Many physical remedial measures, hydrotherapy, electrotherapy, climatotherapy and others, must be important adjuncts. To these is now added psychotherapy. It has been used before, as have most of the other forms of therapy, but in our day we are trying to systematize therapeutic modes so as to secure the greatest possible information with regard to their exact application. This is what must be done with regard to psychotherapy also. Just now its importance is being exaggerated by ardent advocates. In every department of therapy this has always been done by enthusiasts. The business of the practicing physician must be to select what is best, and above all what is sure and harmless, from the many suggestions offered, so as to build up a practical body of applied truth.
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